Effective Parenting Interventions to Reduce Youth ... · 7, 9 This systematic review therefore aims...
Transcript of Effective Parenting Interventions to Reduce Youth ... · 7, 9 This systematic review therefore aims...
REVIEW ARTICLEPEDIATRICS Volume 138 , number 2 , August 2016 :e 20154425
Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic ReviewMichele L. Allen, MD, MS, a Diego Garcia-Huidobro, MD, b, c Carolyn Porta, PhD, MPH, RN, d Dorothy Curran, BS, b Roma Patel, MPH, a Jonathan Miller, MURP, e Iris Borowsky, MD, PhDb
abstractCONTEXT: Parenting interventions may prevent adolescent substance use; however, questions
remain regarding the effectiveness of interventions across substances and delivery qualities
contributing to successful intervention outcomes.
OBJECTIVE: To describe the effectiveness of parent-focused interventions in reducing or
preventing adolescent tobacco, alcohol, and illicit substance use and to identify optimal
intervention targeted participants, dosage, settings, and delivery methods.
DATA SOURCES: PubMed, PsycINFO, ERIC, and CINAHL.
STUDY SELECTION: Randomized controlled trials reporting adolescent substance use outcomes,
focusing on imparting parenting knowledge, skills, practices, or behaviors.
DATA EXTRACTION: Trained researchers extracted data from each article using a standardized,
prepiloted form. Because of study heterogeneity, a qualitative technique known as harvest
plots was used to summarize findings.
RESULTS: A total of 42 studies represented by 66 articles met inclusion criteria. Results
indicate that parenting interventions are effective at preventing and decreasing adolescent
tobacco, alcohol, and illicit substance use over the short and long term. The majority
of effective interventions required ≤12 contact hours and were implemented through
in-person sessions including parents and youth. Evidence for computer-based delivery was
strong only for alcohol use prevention. Few interventions were delivered outside of school or
home settings.
LIMITATIONS: Overall risk of bias is high.
CONCLUSIONS: This review suggests that relatively low-intensity group parenting interventions
are effective at reducing or preventing adolescent substance use and that protection may
persist for multiple years. There is a need for additional evidence in clinical and other
community settings using an expanded set of delivery methods.
Departments of aFamily Medicine and Community Health, and bPediatrics, University of Minnesota Medical School, Minneapolis, Minnesota; cSchool of Medicine, Pontifi cia Universidad
Catolica de Chile, Santiago, Chile; and dDepartment of Population Health and Systems, School of Nursing, and eDivision of Epidemiology and Community Health, School of Public Health,
University of Minnesota, Minneapolis, Minnesota
Dr Allen conceptualized the study, led study design, contributed to data extraction, and wrote the initial draft of the manuscript; Dr Garcia-Huidobro contributed
to study design, led data extraction, and reviewed and revised the manuscript; Dr Porta contributed to study design and reviewed and revised early drafts of the
manuscript; Ms Curran and Ms Patel contributed to data extraction and study design and reviewed and revised early drafts of the manuscript; Mr Miller contributed
To cite: Allen ML, Garcia-Huidobro D, Porta C, et al. Effective Parenting Interventions to Reduce Youth Substance Use: A Systematic Review. Pediatrics.
2016;138(2):e20154425
NIH
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ALLEN et al
Despite recent encouraging
trends, youth tobacco, alcohol, and
other illicit drug use continue to
represent a considerable source of
youth morbidity and mortality and
establish behavioral patterns that
have detrimental health outcomes
into adulthood. 1, 2 There is therefore a
need to identify effective prevention
strategies and to better understand
the delivery qualities contributing to
successful intervention outcomes.
One approach to adolescent
substance use prevention builds on
the recognition that parents play
a key role in promoting healthy
adolescent behaviors and therefore
focuses on strengthening parenting
skills. 2 The influence that parents
have on their adolescent children
has been substantiated by numerous
studies linking a well-defined set of
parenting practices (ie, monitoring,
discipline, communication)
and qualities of parent-youth
relationships (ie, warmth, support,
acceptance, attachment) to
adolescent behavioral outcomes
including substance use. 3, 4 Parenting
interventions for parents of
adolescents broadly focus on building
parent self-efficacy in implementing
skills and engaging with their
children in a manner encouraging
health-protective and preventing risk
behaviors. Previous reviews suggest
that parent-focused interventions
directed at adolescent substance use
are effective; however, to the best of
our knowledge, no systematic review
of parenting interventions delivered
during adolescence has looked across
multiple substances, 3, 5, 6 nor has any
considered intervention delivery
modalities or contexts.
With increasing focus on evidence-
based adolescent health promotion,
and given that poor reach is a known
challenge for parenting interventions,
consideration of evidence
regarding how to most effectively
and efficiently reach families of
adolescents becomes important. 7
Practical questions of interest
from the perspective of future
implementers include the following:
Who needs to be involved, for how
long, in what settings, and through
what means? However, to the best
of our knowledge, no reviews have
comprehensively examined the
state of the evidence regarding
targeted participants (parents
only vs both parents and youth),
minimal dosages required to achieve
outcomes, ideal delivery settings
(schools, community organizations,
clinics, homes), and optimal delivery
modalities. The lack of evidence
regarding success of implementation
within clinics is problematic at a time
when prevention and integrated
services are emerging as pediatric
primary care targets within the
Affordable Care Act. 8 In addition,
although multiple modalities of
program delivery are known to
appeal to parents and increasing
evidence supports the use of online
prevention programming, few
reviews have examined the state
of the literature across delivery
methods for parenting interventions
focused on adolescent substance use
prevention. 7, 9
This systematic review therefore
aims to assess the effectiveness of
parenting interventions over the
short and long term on reducing
adolescent tobacco, alcohol, and illicit
substance use and, secondarily, to
describe effectiveness in relation to
intervention characteristics (targeted
participants, intervention dosage,
delivery settings, and delivery
method), using visual depictions of
qualitative data summaries called
harvest plots. These plots represent
a novel approach to synthesizing
the findings of systematic
reviews focused on complex and
heterogeneous interventions that
cannot be combined into a meta-
analysis. 10 Results of this review will
inform the development, tailoring,
and delivery of parent-focused
interventions to improve adolescent
health.
METHODS
Search Strategy
As reported in the review protocol
(PROSPERO systematic review
registry number CRD42014013069),
we searched PubMed, PsycINFO,
ERIC, and CINAHL for studies
investigating parent-focused
interventions designed to reduce
substance use in adolescents. Search
terms are presented in Table 1. The
search included all dates available by
respective online databases up to the
date of March 1, 2015.
Eligibility Criteria
This review included studies
published in any language
meeting the following criteria:
(1) intervention studies focused
on adolescents (mean age of
participating youth between 10
and 19 years), (2) reported youth
smoking, alcohol, or illicit substance
outcomes (intention, initiation, or
use), and (3) involved parent training
with focus on imparting parenting
knowledge, skills, practices, or
behaviors.
Exclusion criteria were (1) design
not a randomized controlled trial, (2)
adolescents were the participating
parents, (3) intervention focused
on specific populations (eg, parents
of children with cystic fibrosis or
other medical conditions), (4) study
compared 2 parenting interventions
without a usual care condition,
and (5) individual family therapy
interventions distinguished from
parenting-skills interventions in their
focus on changing behaviors though
therapeutic rather than curricular
approaches.
Two independent reviewers (DGH
and RP) screened titles, abstracts,
and full texts of potential articles.
A third reviewer (MLA) resolved
disagreements regarding inclusion of
a study.
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PEDIATRICS Volume 138 , number 2 , August 2016
Data Extraction and Risk of Bias Assessments
All manuscripts were grouped by
study and assigned a study number.
Trained researchers (D.G.H., D.C., and
J.M.) extracted data from each article
using a standardized, prepiloted
form. For studies with multiple arms,
data were only extracted for the arms
that had a parent focus. Extracted
outcomes were adolescent smoking,
alcohol, other illicit substance, and
polysubstance intention to use;
initiation of use; and use. Results
were documented as either reduced,
no change, or increased when
compared with control groups at the
P < .05 level of significance. Time to
follow-up for all reported outcomes
were grouped by time from baseline
as ≤12 months, 12.1 to 24 months,
24.1 to 48 months, and >48 months.
If 2 time points fell within a grouping,
the longest time point presented was
presented.
Risk of bias was evaluated using the
Cochrane Risk of Bias Assessment
Tool, a widely used and validated
tool. 11 Sources of study bias assessed
were a) random sequence generation,
b) allocation concealment, c) blinding
of study personnel and outcome
assessment, d) incomplete outcome
data, and e) selective outcome
reporting. Risk of bias was judged
as low, high, or unclear. A summary
with the criteria for low risk of bias in
each of the domains is presented as
a footnote in the Supplemental Table
3. As per Cochrane systematic review
recommendations, 12 if insufficient
information was presented to permit
judgment, the risk was scored as
“unclear.” To confirm unclear scores,
study protocols were searched,
and authors were contacted asking
additional information on each
source of bias. Two independent
coders (D.G.H. and J.M.) reviewed
each article, study protocol, and
authors’ response to determine
the risk of bias of each study.
Disagreement between coders was
resolved by consensus.
Intervention characteristics extracted
included “targeted participants, ”
classified as parents only, parents
and youth, and multilevel (targeted
teachers, medical providers, or
others). “Intervention dosage”
was calculated as the amount of
time parents were intended to
participate in the intervention
and was classified into low (≤12
parent-hours), moderate (12.1–24
parent-hours), and high (>24
parent-hours). “Delivery setting”
was defined as the primary location
of intervention, classified as home,
school, community agency, or
combination. The primary “method
of intervention delivery” was
categorized as in-person, typically
group sessions with a professional;
workbook based; computer based; or
a combination. Additional extracted
data included youth age described as
a range in years or grade level and
sex as percent female. Participant
race/ethnicity was classified as
reported by authors or by the race/
ethnicity that comprised >75%
of the participants or as diverse
populations if no one race/ethnicity
comprised >75% of the participants.
Data Synthesis
We used harvest plots to graphically
synthesize the findings for the study
aims. 10 In these plots, each study
or study arm for those evaluating
multiple interventions is represented
by a bar, and the properties of the bar
represent features of the study. The
height presents the study risk of bias;
taller bars represent studies with
fewer sources of bias. Because some
studies did not achieve low risk of
bias on any criteria and thus received
a count of zero, the heights on the
harvest plots represent the raw
counts plus 1. The location within a
column represents the study results
classified as detrimental effect, no
difference, or positive effect using
an α of .05. The bar’s color or fill and
location within a row represent the
analyses of interest.
For the first aim, to assess the efficacy
of the parenting interventions (see
Fig 2), we included all adolescent
smoking, alcohol, and illicit substance
use outcomes for all reported time
points within each study. The bar
color indicates whether substance
use (black), substance use initiation
(gray), or substance use intention
(white) was reported in the study.
When >1 outcome was reported for a
substance, we presented 1 outcome
based on the following hierarchy:
use, initiation, and intention. The
3
TABLE 1 Search Terms Used to Search for Articles in PubMed, ERIC, CINAHL, and PsycInfo
PubMed
(“Family”[Mesh] OR Famil* OR Parent*) AND “Adolescent”[Mesh] AND (“Clinical Trial” [Publication Type] OR “Clinical Trials as
Topic”[Mesh]) AND (“Alcohol Drinking”[Mesh] OR “Smoking”[Mesh] OR “Substance-Related Disorders”[Mesh] OR smok* OR
substance* OR alcohol* OR marijuana* OR cocaine* OR amphetamine* OR heroine*)
ERIC
(parent* OR famil*) AND (“Clinical Trials+” OR Randomized OR “Parenting Education” OR “parent education”) AND (Adol* OR
teen* OR youth*) AND (tobacco or smok* or alcohol OR substance or marijuana or cocaine or heroin or methamphetamine or
amphetamine or prescription or drug*)
CINAHL
(parent* OR famil*) AND (“Clinical Trials+” OR Randomized OR “Parenting Education” OR “parent education”) AND (Adol* OR
teen* OR youth*) AND (tobacco or smok* or alcohol OR substance or marijuana or cocaine or heroin or methamphetamine or
amphetamine or prescription or drug*)
PSYCINFO
(adolescent or teen or youth or adolescents or teens or youths or adolescence) AND (exp family/ or exp Parents/ or exp Parenting
Skills/ or exp Family Relations/ or exp Parenting/ or exp Parent Child Relations/) AND (exp Parent Training/ or exp clinical
trials/ or exp Family Intervention/ or exp Intervention/) AND (exp Alcohols/ OR exp Drugs/ or drug.mp OR exp Tobacco Smoking/
OR smoking.mp OR tobacco.mp)
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ALLEN et al
bar’s location within rows represent
the follow-up times that the
study reported. The 4 studies
reporting only polysubstance use
outcomes are not included in the
harvest plots.
For the second aim, to determine
the interventions’ characteristics
associated with efficacy (see Figs
3– 5), harvest plots synthesize dose
intensity, delivery setting, and
delivery method for each substance.
Only studies reporting these
characteristics were included in the
plots. In these harvest plots, the bar
pattern indicates the longest time
point of follow-up for each study;
white = ≤12 months, dotted = 12.1 to
24 months, horizontal stripes =
24.1 to 48 months, black = >48
months. The bar’s location within
rows represents the characteristic
of the intervention in each study.
Participant types (eg, parents vs
parents and youth) were
not presented in harvest plots
because of a lack of variability.
Because comparing counts between
the number of studies with positive
and null results based on the study’s
P value for the difference between
intervention and control groups
might be misleading, 13 we conducted
a binomial test of proportions for
each outcome of interest, using the
following formula:
X score = [ H - Kp / Kp ( 1-p ) 1/2 ] ,
where H is the number of positive
studies, K is the number of total
studies with the characteristic of
interest, and p is the criterion for
positivity by a 2-sided test (0.05 /
2 = 0.025). 13 P values were calculated
from a normal distribution. We
defined a “positive” study as one
reporting results with P values ≤.05
or lower; under the null hypothesis,
1 in 20 studies would be expected
to meet this criterion. A significant
Xscore suggests that there is sufficient
evidence to conclude that the
proportion of studies showing
effective outcomes is greater than
what would have been found by
chance. 13 Using this same formula,
we calculated the number of studies
that would need to be null to change
the conclusions of the review in any
given category.
RESULTS
Of the 1883 studies identified, 1721
unique articles were screened ( Fig
1). A total of 1644 articles were
excluded, largely because they did not
evaluate family skills interventions,
did not focus on substance use, or
were not randomized controlled
trials. The remaining 77 articles were
screened in full, and 11 additional
articles (representing 7 studies) were
excluded because (1) parents were
not a target of the intervention (n =
2), (2) the study targeted a population
with a specific medical problem (n =
2), (3) youth substance use outcomes
were not reported (n = 3), or (4) study
did not meet methodological inclusion
criteria (n = 4).
The final 66 manuscripts included
in the review represented 42
unique studies ( Table 2); 6 of
these studies included multiple
parent-focused arms. Studies and
associated citations will hereafter
be referred to by the study number
in Table 2 with letter subscripts
indicating arms for multiarmed
studies (eg, 9[a], 9[b]). Some
manuscripts reported combined
data from multiple studies and
are therefore presented in Table 2
multiple times.
4
FIGURE 1Study fl ow diagram. From Moher D, Liberati A, Tetzlaff J, Altman DG; The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med. 2009;151(4):264–269.
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PEDIATRICS Volume 138 , number 2 , August 2016 5
TABL
E 2
Su
mm
ary
of S
tud
ies
Usi
ng
Par
ent-
Focu
sed
Inte
rven
tion
s to
Red
uce
You
th S
ub
stan
ce U
se
Stu
dy
IDAu
thor
sYo
uth
Dem
ogra
ph
ics
Inte
rven
tion
Des
crip
tion
Con
trol
Des
crip
tion
Ou
tcom
es M
easu
red
Res
ult
sa (P
< .0
5)
Nu
mb
er L
ow R
isk
of B
ias
Cri
teri
ab
1B
aum
an e
t al
(200
1) 14
N =
132
6; F
emal
e N
A; R
ace
NA;
12–
14 y
4 b
ookl
ets
+ 4
fol
low
-up
cal
ls
(par
ent)
No
inte
rven
tion
Sm
okin
g in
itia
tion
;
alco
hol
use
an
d
init
iati
on
12 m
o: n
o d
iffe
ren
ce s
mok
ing
use
or
alco
hol
use
1
2B
rod
y et
al
(200
6) 15
N =
332
; 53.
6% F
emal
e;
Afri
can
Am
eric
an; 1
1–13
.5
y
7 se
ssio
ns
(you
th +
par
ents
)3
leafl
ets
Alco
hol
use
an
d
inte
nti
on
3 m
o: r
edu
ced
alc
ohol
init
iati
on/
use
; 29
mo:
red
uce
d a
lcoh
ol
init
iati
on/u
se
3
3B
rod
y et
al
(201
0) 16
N =
667
; Fem
ale
(NA)
; Afr
ican
Amer
ican
; 10.
8 y
5 se
ssio
ns
(you
th +
par
ents
)3
leafl
ets
Alco
hol
use
an
d
init
iati
on
29 m
o: r
edu
ced
alc
ohol
use
; 65
mo:
red
uce
d a
lcoh
ol u
se
2
4B
rod
y et
al
(201
2) 17
N =
502
; 51%
Fem
ale;
Afr
ican
Amer
ican
; Age
16
y (1
0th
grad
e)
5 se
ssio
ns
(you
th +
par
ents
)5
sess
ion
s on
nu
trit
ion
(you
th +
par
ents
)
Sm
okin
g, a
lcoh
ol,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
22 m
o: r
edu
ced
pol
ysu
bst
ance
use
1
5C
onn
ell e
t al
(200
6, 18
200
7) 19
N =
998
; 47.
3% F
emal
e;
Div
erse
pop
ula
tion
;
11–
17 y
6 se
ssio
ns
(you
th)
+ 3
fam
ily
chec
kup
s +
ele
ctiv
e fa
mily
inte
rven
tion
(yo
uth
+
par
ents
)
No
inte
rven
tion
Sm
okin
g, a
lcoh
ol,
sub
stan
ce
72 m
o: r
edu
ced
sm
okin
g u
se,
alco
hol
use
, an
d s
ub
stan
ce
use
4
6C
urr
y et
al
(200
3) 20
N =
402
6; 5
2% F
emal
e;
Pri
mar
ily w
hit
e; 1
0–12
y
1 h
and
boo
k +
2 c
oun
selin
g
calls
+ 1
new
slet
ter
(par
ent)
Sta
nd
ard
car
eS
mok
ing
inte
nti
on
and
use
6 m
o: n
o d
iffe
ren
ce s
mok
ing
inte
nti
on, o
r u
se; 1
2 m
o: n
o
dif
fere
nce
sm
okin
g in
ten
tion
,
or u
se; 2
0 m
o: n
o d
iffe
ren
ce
smok
ing
inte
nti
on, o
r u
se
1
7D
eGar
mo
et a
l
(200
9) 21
N =
361
; 51%
Fem
ale;
Euro
pea
n A
mer
ican
;
5th
–12
th g
rad
e
6 se
ssio
ns
(you
th +
par
ent)
+ r
eces
s ga
mes
(yo
uth
+
teac
her
) +
7 p
hon
e ca
lls
(par
ent)
+ n
ewsl
ette
rs
(tea
cher
+ p
aren
t)
No
inte
rven
tion
Sm
okin
g, a
lcoh
ol, a
nd
sub
stan
ce u
se a
nd
init
iati
on
60 m
o: r
edu
ced
sm
okin
g
and
alc
ohol
init
iati
on, n
o
dif
fere
nce
su
bst
ance
init
iati
on
4
8D
emb
o et
al
(200
2) 22
N =
315
; 44%
Fem
ale;
Div
erse
pop
ula
tion
; 14.
5 y
30 h
ome
visi
ts (
you
th +
par
ent)
Ph
one
con
tact
s w
ith
staf
f an
d r
efer
rals
if
nec
essa
ry
Alco
hol
use
36 m
o: n
o d
iffe
ren
ce a
lcoh
ol u
se1
9(a)
Dis
hio
n &
And
rew
s
(199
5) 23
N =
65;
47.
5% F
emal
e; 9
0%
Cau
casi
an; 1
0–14
y
12 s
essi
ons
+ 6
new
slet
ter
(par
ents
)
No
inte
rven
tion
Sm
okin
g an
d
sub
stan
ce u
se
4 m
o: n
o ch
ange
sm
okin
g u
se; 1
6
mo:
no
chan
ge s
mok
ing
use
1
9(b
)D
ish
ion
&
And
rew
s
(199
5) 23
N =
70;
47.
5% F
emal
e; 9
0%
Cau
casi
an; 1
0–14
y
12 s
essi
ons
+ 6
new
slet
ter
(you
th +
par
ents
)
No
inte
rven
tion
Sm
okin
g an
d
sub
stan
ce u
se
4 m
o: in
crea
sed
sm
okin
g u
se; 1
6
mo:
incr
ease
d s
mok
ing
use
1
10Fa
ng
L, e
t al
(201
0) 24
N =
108
; 100
% F
emal
e; A
sian
Amer
ican
; 10–
14 y
9 on
line
sess
ion
s (y
outh
+
par
ent)
No
trea
tmen
tS
mok
ing
and
alc
ohol
use
; su
bst
ance
use
and
inte
nti
on
6.25
mo:
no
dif
fere
nce
sm
okin
g
use
, red
uce
d a
lcoh
ol
use
, su
bst
ance
use
, an
d
pol
ysu
bst
ance
inte
nti
on
4
11Fo
rman
SG
et
al
(199
0) 25
N =
279
; Fem
ale
(NA)
; Wh
ite;
14.7
2 y
10 y
outh
ses
sion
s +
1 b
oost
er
+ 5
par
ent
sess
ion
s (y
outh
+ p
aren
t)
10 s
essi
ons
+ 2
boo
ster
on p
eer
sup
por
t,
incr
ease
su
bst
ance
know
led
ge (
you
th
only
)
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se
12 m
o: n
o d
iffe
ren
ce s
mok
ing
use
or
alco
hol
use
, red
uce
d
sub
stan
ce u
se
2
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ALLEN et al 6
Stu
dy
IDAu
thor
sYo
uth
Dem
ogra
ph
ics
Inte
rven
tion
Des
crip
tion
Con
trol
Des
crip
tion
Ou
tcom
es M
easu
red
Res
ult
sa (P
< .0
5)
Nu
mb
er L
ow R
isk
of B
ias
Cri
teri
ab
12G
onza
les
et a
l
(201
2) 26
N =
516
; 50.
8% F
emal
e;
Mex
ican
Am
eric
an; 1
2.3
y
9 se
ssio
ns
+ 2
hom
e vi
sits
(you
th +
par
ent)
1 w
orks
hop
on
sch
ool
reso
urc
es/
sch
ool
succ
ess
(you
th +
par
ent)
Sm
okin
g, a
lcoh
ol,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
12 m
o: r
edu
ced
pol
ysu
bst
ance
use
4
13G
uila
mo-
Ram
os
et a
l (20
10) 27
N =
138
6; 5
0.4%
Fem
ale;
Div
erse
pop
ula
tion
; 12.
1 y
2 yo
uth
ses
sion
s +
2 p
aren
t
sess
ion
s +
2 b
oost
er c
alls
(you
th +
par
ent)
2 yo
uth
ses
sion
s +
par
ent
clas
s on
hig
h
sch
ool s
elec
tion
Sm
okin
g u
se15
mo:
red
uce
d s
mok
ing
use
4
14(a
)H
agge
rty
et a
l
(200
7) 28
N =
213
; 48.
7% F
emal
e; 5
0.8%
Cau
casi
an, 4
9.2%
Afr
ican
Amer
ican
; 13.
7 y
(8th
grad
e)
Inte
rven
tion
1: s
elf-
adm
inis
tere
d v
ideo
+
wor
kboo
k p
rogr
am (
par
ent)
No
trea
tmen
tS
mok
ing
init
iati
on;
alco
hol
, su
bst
ance
and
pol
ysu
bst
ance
use
an
d in
itia
tion
24 m
o: n
o ch
ange
in t
obac
co,
alco
hol
, su
bst
ance
or
pol
y
sub
stan
ce in
itia
tion
1
14(b
)H
agge
rty
et a
l
(200
7) 28
N =
224
; 48.
7% F
emal
e;
50.8
%; C
auca
sian
, 49.
2%
Afri
can
Am
eric
an; 1
3.7
y
(8th
gra
de)
Inte
rven
tion
2: 7
Gro
up
vid
eo +
wor
kboo
k se
ssio
ns
(you
th
+ p
aren
t)
No
trea
tmen
tS
mok
ing
init
iati
on;
alco
hol
, su
bst
ance
and
pol
ysu
bst
ance
use
an
d in
itia
tion
24 m
o: n
o ch
ange
in t
obac
co,
alco
hol
, su
bst
ance
or
pol
ysu
bst
ance
init
iati
on
1
15Ko
mro
et
al
(200
6, 29
200
8) 30
N =
581
2; 5
0% F
emal
e;
Div
erse
pop
ula
tion
; 11.
8 y
(6th
gra
de)
You
th: 2
5 se
ssio
ns
+ 9
.5 p
eer
lead
ersh
ips
trai
nin
g +
com
mu
nit
y se
rvic
e p
roje
ct.
You
th +
par
ent:
12
at
hom
e b
ookl
ets+
2 f
amily
fun
eve
nts
+ 1
3 p
aren
t
pos
tcar
ds
(you
th +
par
ent)
Sta
nd
ard
car
eAl
coh
ol in
ten
tion
;
alco
hol
an
d
pol
ysu
bst
ance
use
36 m
o: n
o d
iffe
ren
ce a
lcoh
ol
inte
nti
on, a
lcoh
ol o
r
pol
ysu
bst
ance
use
2
16(a
)Ko
nin
g (2
009,
31
2011
, 32 2
013)
33
N =
173
6; 4
9% F
emal
e; D
utc
h;
12.6
y
Inte
rven
tion
1: 1
pre
sen
tati
on
+ 1
par
ent
con
sen
sus
mee
tin
g fo
r ru
le m
akin
g +
1
info
rmat
ion
leafl
et
(par
ent)
No
inte
rven
tion
Alco
hol
use
10 m
o: n
o d
iffe
ren
ce a
lcoh
ol u
se;
22 m
o: n
o d
iffe
ren
ce a
lcoh
ol
use
; 34
mo:
no
dif
fere
nce
alco
hol
use
; 50
mo:
no
dif
fere
nce
alc
ohol
use
3
16(b
)Ko
nin
g (2
009,
31
2011
, 32 2
013)
33
N =
174
7; 4
9% F
emal
e; D
utc
h;
12.6
y
Inte
rven
tion
2: 1
pre
sen
tati
on
+ 1
par
ent
con
sen
sus
mee
tin
g fo
r ru
le m
akin
g +
1
info
rmat
ion
leafl
et
(par
ent)
+ 4
less
ons
+ 1
boo
ster
sess
ion
(yo
uth
)
No
inte
rven
tion
Alco
hol
use
10 m
o: r
edu
ced
alc
ohol
use
; 22
mo:
red
uce
d a
lcoh
ol u
se; 3
4
mo:
red
uce
d a
lcoh
ol u
se; 5
0
mo:
red
uce
d a
lcoh
ol u
se
3
17Lo
vela
nd
-Ch
erry
et a
l (19
99) 34
N =
892
; 54%
Fem
ale;
Euro
pea
n A
mer
ican
; 9 y
(4th
gra
de)
3 h
ome
sess
ion
s +
ph
one
calls
+ n
ewsl
ette
r
No
inte
rven
tion
Alco
hol
use
an
d
init
iati
on
60 m
o: r
edu
ced
alc
ohol
use
1
18M
arti
nez
et
al
(200
5) 35
N =
73;
44%
Fem
ale;
Lat
ino;
12.7
4 y
(mid
dle
sch
ool)
12 s
essi
ons
+ 1
2 n
oteb
ook
exer
cise
s (p
aren
t)
No
pro
ject
-rel
ated
inte
rven
tion
Sm
okin
g, a
lcoh
ol
and
su
bst
ance
inte
nti
on
5.61
mo:
red
uce
d s
mok
ing
inte
nti
on, m
argi
nal
ly r
edu
ced
sub
stan
ce in
ten
tion
, no
dif
fere
nce
alc
ohol
inte
nti
on
1
19M
ilbu
rn e
t al
(201
2) 36
N =
151
; 66.
2% F
emal
e;
Div
erse
pop
ula
tion
; 14.
8 y
5 se
ssio
ns
(you
th +
par
ent)
Sta
nd
ard
car
eAl
coh
ol, s
ub
stan
ce
and
pol
ysu
bst
ance
use
12 m
o: r
edu
ced
alc
ohol
use
,
incr
ease
d m
ariju
ana
use
,
red
uce
d h
ard
su
bst
ance
use
3
TABL
E 2
Con
tin
ued
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 138 , number 2 , August 2016 7
Stu
dy
IDAu
thor
sYo
uth
Dem
ogra
ph
ics
Inte
rven
tion
Des
crip
tion
Con
trol
Des
crip
tion
Ou
tcom
es M
easu
red
Res
ult
sa (P
< .0
5)
Nu
mb
er L
ow R
isk
of B
ias
Cri
teri
ab
20(a
)O
’Don
nel
l et
al
(201
0) 37
N =
268
; 100
% F
emal
e;
Div
erse
pop
ula
tion
;
11–
13 y
Inte
rven
tion
1: 4
au
dio
CD
s
(you
th +
par
ent)
No
mat
eria
lsAl
coh
ol u
se12
mo:
red
uce
d a
lcoh
ol u
se1
20(b
)O
’Don
nel
l et
al
(201
0) 37
N =
268
; 100
% F
emal
e;
Div
erse
pop
ula
tion
;
11–
13 y
Inte
rven
tion
2: 4
boo
klet
s
(you
th +
par
ent)
No
mat
eria
lsAl
coh
ol u
se12
mo:
no
chan
ge in
alc
ohol
use
1
21P
anti
n e
t al
(200
9) 38
N =
213
; 36%
Fem
ale;
His
pan
ic; 1
3.8
y (8
th
grad
e)
9 gr
oup
ses
sion
s +
10 f
amily
visi
ts +
4 b
oost
er s
essi
ons
(you
th +
par
ent)
3 in
div
idu
al a
nd
fam
ily r
efer
rals
to
agen
cies
th
at s
erve
del
inq
uen
t yo
uth
Sm
okin
g, a
lcoh
ol,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
30 m
o: r
edu
ced
pol
ysu
bst
ance
use
3
22P
erry
et
al
(199
6, 39
200
2) 40
Will
iam
s et
al
(199
9) 41
N =
235
1; 4
8.7%
Fem
ale;
94%
Cau
casi
an; 6
th g
rad
e at
bas
elin
e
Pro
ject
Nor
thla
nd
: cla
ssro
om
less
ons,
sch
ool e
nvi
ron
men
t
enh
ance
men
ts, p
aren
t
new
slet
ters
an
d w
orkb
ooks
,
com
mu
nit
y en
viro
nm
ent
enh
ance
men
ts
Sta
nd
ard
car
eS
mok
ing,
alc
ohol
,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
;
alco
hol
inte
nti
on
and
init
iati
on
<6
mo:
no
dif
fere
nce
sm
okin
g,
alco
hol
or
sub
stan
ce u
se o
r
alco
hol
inte
nti
on; 1
2 m
o: n
o
dif
fere
nce
sm
okin
g, a
lcoh
ol
or s
ub
stan
ce u
se o
r al
coh
ol
inte
nti
on; 2
4 m
o: n
o d
iffe
ren
ce
smok
ing
or s
ub
stan
ce u
se,
red
uce
d a
lcoh
ol in
ten
tion
,
init
iati
on a
nd
use
, red
uce
d
pol
y-su
bst
ance
use
; 4 y
:
red
uce
d a
lcoh
ol u
se a
nd
inte
nti
on; 6
y: r
edu
ced
alc
ohol
use
an
d in
ten
tion
0
23P
rad
o et
al
(200
7) 42
N =
266
; 51.
9% F
emal
e;
His
pan
ic; 1
3.4
(8th
gra
de)
15 s
essi
ons
+ 8
fam
ily v
isit
s +
2 “c
ircl
es”
on p
aren
tin
g an
d
pre
ven
tin
g su
bst
ance
use
and
ris
ky s
exu
al b
ehav
ior
(you
th +
par
ent)
Con
trol
1: 8
ES
OL
clas
ses
(par
ent)
+ 6
grou
p s
essi
ons
+ 2
fam
ily v
isit
s on
ris
ky
sexu
al b
ehav
ior
(you
th +
par
ent)
.
Con
trol
2: 8
ES
OL
clas
ses
(par
ent)
+
7 gr
oup
ses
sion
s
of f
amily
exe
rcis
e
(you
th +
par
ent)
Sm
okin
g, a
lcoh
ol,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
and
init
iati
on
36 m
o: r
edu
ced
sm
okin
g u
se a
nd
init
iati
on, r
edu
ced
su
bst
ance
use
com
par
ing
inte
rven
tion
wit
h c
ontr
ol 2
bu
t n
ot w
hen
com
par
ing
inte
rven
tion
wit
h c
ontr
ol 1
; no
dif
fere
nce
alco
hol
use
or
alco
hol
or
sub
stan
ce in
itia
tion
3
24P
rad
o et
al
(201
2) 43
N =
242
; 35.
6% F
emal
e;
His
pan
ic o
r La
tin
o; 1
4.7
y
8 p
aren
t gr
oup
ses
sion
s +
4 fa
mily
vis
its
(you
th +
par
ent)
Sta
nd
ard
car
e:
incl
ud
ed r
efer
rals
for
fam
ilies
Alco
hol
, su
bst
ance
and
pol
ysu
bst
ance
use
12 m
o: r
edu
ced
pol
ysu
bst
ance
and
su
bst
ance
use
, no
dif
fere
nce
alc
ohol
use
4
25R
iesc
h e
t al
(201
2) 44
N =
167
; 48.
5% F
emal
e;
Div
erse
pop
ula
tion
; 9–
11 y
,
10.8
y a
vera
ge a
ge
7 se
ssio
ns
(you
th +
par
ent)
No
inte
rven
tion
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se
6 m
o: n
o ch
ange
in s
mok
ing,
alco
hol
or
sub
stan
ce u
se
3
TABL
E 2
Con
tin
ued
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
ALLEN et al 8
Stu
dy
IDAu
thor
sYo
uth
Dem
ogra
ph
ics
Inte
rven
tion
Des
crip
tion
Con
trol
Des
crip
tion
Ou
tcom
es M
easu
red
Res
ult
sa (P
< .0
5)
Nu
mb
er L
ow R
isk
of B
ias
Cri
teri
ab
26S
chin
ke e
t al
(200
4, 45
201
0) 46
Sch
win
n e
t al
(201
0) 47
N =
325
; 51.
4% F
emal
e;
Div
erse
pop
ula
tion
;
10–
12 y
10 o
nlin
e se
ssio
ns
(you
th)
+ 1
vid
eota
pe
+ 2
new
slet
ters
+ 1
boo
ster
wor
ksh
ops
(par
ent)
No
inte
rven
tion
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se a
nd
inte
nti
on
<6
mo:
red
uce
d s
mok
ing,
alco
hol
, an
d s
ub
stan
ce u
se; 1
2
mo:
red
uce
d s
mok
ing,
alc
ohol
,
and
su
bst
ance
use
; 24
mo:
red
uce
d s
mok
ing,
alc
ohol
,
and
su
bst
ance
use
; 36
mo:
red
uce
d s
mok
ing,
alc
ohol
, an
d
sub
stan
ce u
se; 6
y: r
edu
ced
smok
ing
and
alc
ohol
use
, no
chan
ge in
su
bst
ance
use
; 7 y
:
red
uce
d s
mok
ing,
alc
ohol
use
;
red
uce
d a
lcoh
ol in
ten
tion
; no
dif
fere
nce
su
bst
ance
use
1
27S
chin
ke e
t al
(200
9) 48
N =
202
; 100
% F
emal
e;
Div
erse
pop
ula
tion
;
10–
13 y
14 o
nlin
e m
odu
les
(you
th +
par
ent)
No
trea
tmen
tAl
coh
ol u
se in
ten
tion
2 m
o: r
edu
ced
alc
ohol
use
, no
effe
ct o
n a
lcoh
ol in
ten
tion
2
28S
chin
ke e
t al
(200
9) 49
N =
916
; 100
% F
emal
e;
Div
erse
pop
ula
tion
;
11–
13 y
9 on
line
sess
ion
s +
2 o
nlin
e
boo
ster
ses
sion
s (y
outh
+
par
ent)
No
inte
rven
tion
Sm
okin
g, a
lcoh
ol
and
su
bst
ance
use
an
d in
ten
tion
;
pol
ysu
bst
ance
inte
nti
on
24 m
o: r
edu
ced
alc
ohol
and
su
bst
ance
use
an
d
pol
ysu
bst
ance
inte
nti
on; n
o
chan
ge in
sm
okin
g u
se
1
29S
chin
ke e
t al
(200
9) 50
N =
591
; 100
% F
emal
e;
Div
erse
pop
ula
tion
; 12.
7 y
9 on
line
sess
ion
s (y
outh
+
par
ent)
No
inte
rven
tion
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se a
nd
inte
nti
on
12 m
o: n
o ch
ange
sm
okin
g
use
; red
uce
d a
lcoh
ol u
se,
sub
stan
ce in
ten
tion
& u
se
3
30S
chin
ke, S
P
(201
1) 51
N =
546
; 100
% F
emal
e;
Div
erse
pop
ula
tion
;
10–
13 y
10 o
nlin
e se
ssio
ns
(you
th +
par
ent)
No
inte
rven
tion
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se;
pol
ysu
bst
ance
inte
nti
on
≤6 m
o: r
edu
ced
, alc
ohol
use
and
pol
ysu
bst
ance
inte
nti
on;
no
chan
ge in
tob
acco
or
sub
stan
ce u
se
2
31S
imon
s-M
orto
n
(200
5) 52
N =
265
1; F
emal
e (N
A); R
ace
NA;
6th
gra
de
18 c
lass
room
less
ons
+ 1
par
ent
vid
eo a
nd
boo
klet
+ e
nh
ance
d s
choo
l
envi
ron
men
t
Sch
ool d
istr
ict
com
par
ison
gro
up
Sm
okin
g an
d a
lcoh
ol
use
an
d in
ten
tion
36 m
o: r
edu
ced
sm
okin
g
inte
nti
on a
nd
use
3
32S
pir
ito
(201
1) 53
N =
125
; 53%
Fem
ale;
Div
erse
pop
ula
tion
; 13–
17 y
Ind
ivid
ual
mot
ivat
ion
al
inte
rvie
w (
you
th)
+ 1
fam
ily
sess
ion
s (y
outh
+ p
aren
t)
Ind
ivid
ual
mot
ivat
ion
al
inte
rvie
w (
you
th)
Alco
hol
use
3 m
o: r
edu
ced
alc
ohol
use
3
TABL
E 2
Con
tin
ued
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 138 , number 2 , August 2016 9
Stu
dy
IDAu
thor
sYo
uth
Dem
ogra
ph
ics
Inte
rven
tion
Des
crip
tion
Con
trol
Des
crip
tion
Ou
tcom
es M
easu
red
Res
ult
sa (P
< .0
5)
Nu
mb
er L
ow R
isk
of B
ias
Cri
teri
ab
33S
pot
h e
t al
(199
9, 54
2001
, 55
2004
, 56
2006
, 57
2006
, 58
2008
) 59,
Par
k et
al
(200
0) 60
,
Mas
on e
t al
(200
3) 61
, Gu
yll
et a
l (20
04) 62
N =
429
; 52%
Fem
ale;
99%
Cau
casi
an; 6
th g
rad
e
Pre
par
ing
for
Dru
g Fr
ee Y
ears
(PD
FY):
4 s
essi
ons
(par
ent)
+ 1
ses
sion
(yo
uth
+ p
aren
t)
4 le
afl e
ts o
n a
dol
esce
nt
dev
elop
men
t
(par
ent)
Sm
okin
g, a
lcoh
ol,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
and
inte
nti
on
12 m
o: n
o ch
ange
in s
mok
ing,
alco
hol
, su
bst
ance
or
pol
ysu
bst
ance
init
iati
on o
r
use
; 24
mo:
red
uce
d s
mok
ing,
alco
hol
, su
bst
ance
an
d
pol
ysu
bst
ance
init
iati
on/u
se;
48 m
o: r
edu
ced
, alc
ohol
use
,
mar
gin
ally
red
uce
d s
mok
ing,
alco
hol
, su
bst
ance
init
iati
on,
no
chan
ge in
tob
acco
or
sub
stan
ce u
se; 6
y: r
edu
ced
smok
ing
init
iati
on &
use
,
no
chan
ge in
alc
ohol
or
sub
stan
ce in
itia
tion
or
use
; 10
y: m
argi
nal
ly r
edu
ced
mis
use
of p
resc
rip
tion
dru
gs
3
34S
pot
h e
t al
(199
9, 54
1999
, 63
2001
, 55
2004
, 56
2006
, 57
2006
, 58
2008
, 59
2009
, 64
2012
) 65,
Gu
yll e
t al
(200
4)62
N =
446
; 52%
Fem
ale;
99%
Cau
casi
an; 6
th g
rad
e
Inte
rven
tion
: Iow
a
Str
engt
hen
ing
Fam
ilies
Pro
gram
(IS
FP):
7 s
essi
ons
(you
th +
par
ent)
4 le
afl e
ts o
n a
dol
esce
nt
dev
elop
men
t
(par
ent)
Sm
okin
g, a
lcoh
ol,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
and
inte
nti
on
12 m
o: R
edu
ced
alc
ohol
init
iati
on
no
chan
ge in
sm
okin
g,
sub
stan
ce o
r p
olys
ub
stan
ce
init
iati
on o
r u
se o
r al
coh
ol
use
; 24
mo:
red
uce
d s
mok
ing,
alco
hol
, su
bst
ance
an
d
pol
ysu
bst
ance
init
iati
on a
nd
mar
gin
ally
red
uce
d s
mok
ing,
alco
hol
, su
bst
ance
an
d
pol
ysu
bst
ance
use
; 48
mo:
red
uce
d s
mok
ing,
alc
ohol
,
sub
stan
ce a
nd
pol
ysu
bst
ance
init
iati
on, r
edu
ced
tob
acco
and
alc
ohol
use
no
chan
ge in
sub
stan
ce u
se; 6
y: r
edu
ced
smok
ing,
alc
ohol
, su
bst
ance
and
pol
ysu
bst
ance
init
iati
on,
red
uce
d a
lcoh
ol, s
ub
stan
ce
and
pol
ysu
bst
ance
use
,
no
chan
ge in
tob
acco
use
;
10 y
: red
uce
d m
isu
se o
f
pre
scri
pti
on d
rugs
3
TABL
E 2
Con
tin
ued
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
ALLEN et al 10
Stu
dy
IDAu
thor
sYo
uth
Dem
ogra
ph
ics
Inte
rven
tion
Des
crip
tion
Con
trol
Des
crip
tion
Ou
tcom
es M
easu
red
Res
ult
sa (P
< .0
5)
Nu
mb
er L
ow R
isk
of B
ias
Cri
teri
ab
35S
pot
h e
t al
(200
2, 66
2005
, 67
2008
) 68,
Sp
oth
et
al
(200
6, 57
, 58
2008
) 59
des
crib
es
2 st
ud
ies
(in
clu
din
g
this
1)
N =
166
4; 4
7% f
emal
e;
Cau
casi
an; 7
th g
rad
e
7 se
ssio
ns
(you
th +
par
ent)
4 le
afl e
ts o
n a
dol
esce
nt
dev
elop
men
t
(par
ent)
Sm
okin
g, a
lcoh
ol,
sub
stan
ce a
nd
pol
ysu
bst
ance
use
; alc
ohol
and
su
bst
ance
init
iati
on
12 m
o: n
o d
iffe
ren
ce s
mok
ing
init
iati
on; r
edu
ced
alc
ohol
init
iati
on, s
ub
stan
ce in
itia
tion
,
and
pol
y su
bst
ance
init
iati
on;
2.5
y: r
edu
ced
pol
y su
bst
ance
init
iati
on; n
o ch
ange
sub
stan
ce u
se; 5
.5 y
: red
uce
d
smok
ing
init
iati
on/u
se,
alco
hol
init
iati
on, s
ub
stan
ce
use
, an
d p
oly
sub
stan
ce
init
iati
on/u
se; n
o ch
ange
alco
hol
use
or
sub
stan
ce
init
iati
on
3
36S
pot
h e
t al
(200
7, 69
2011
, 70
2013
) 71,
Red
mon
d
et a
l (20
09) 72
N =
11
931;
51%
Fem
ale;
85%
Cau
casi
an; 6
th g
rad
e at
bas
elin
e
Year
1: S
tren
gth
enin
g Fa
mili
es
Pro
gram
(10
–14
y):
7
sess
ion
s (y
outh
+ p
aren
t).
Year
2: i
n-c
lass
less
ons
on
sub
stan
ce a
void
ance
(yo
uth
)
No
pro
ject
su
pp
ort
Sm
okin
g, a
lcoh
ol
and
su
bst
ance
use
, in
itia
tion
and
inte
nti
on;
pol
ysu
bst
ance
init
iati
on a
nd
inte
nti
on
12 m
o: r
edu
ced
su
bst
ance
init
iati
on a
nd
use
, red
uce
d
pol
y-su
bst
ance
init
iati
on,
mar
gin
ally
red
uce
d t
obac
co
use
an
d in
itia
tion
, no
chan
ge
in a
lcoh
ol u
se o
r in
itia
tion
; 2
y: n
o d
iffe
ren
ce p
olys
ub
stan
ce
inte
nti
on; 4
y: r
edu
ced
smok
ing,
alc
ohol
, su
bst
ance
and
pol
ysu
bst
ance
init
iati
on;
red
uce
d s
ub
stan
ce u
se;
mar
gin
ally
red
uce
d t
obac
co
use
; no
chan
ge in
alc
ohol
use
;
6 y:
red
uce
d s
mok
ing
and
sub
stan
ce u
se; n
o ch
ange
in
alco
hol
use
1
37(a
)S
tan
ton
et
al
(200
4) 73
N =
579
; 58%
Fem
ale;
100
%
Afri
can
Am
eric
an; 1
3–16
y
Inte
rven
tion
1: I
nte
rven
tion
1 +
1 vi
deo
(yo
uth
+ p
aren
t)
8 yo
uth
ses
sion
s al
one
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se
24 m
o: r
edu
ced
sm
okin
g u
se; n
o
chan
ge a
lcoh
ol u
se; m
argi
nal
chan
ge in
su
bst
ance
use
2
37(b
)S
tan
ton
B, e
t al
(200
4) 73
N =
559
; 58%
Fem
ale;
100
%
Afri
can
Am
eric
an; 1
3-16
Inte
rven
tion
2: I
nte
rven
tion
1
+ 4
boo
ster
ses
sion
s (y
outh
+ p
aren
t)
8 yo
uth
ses
sion
s al
one
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se
24 m
o: r
edu
ced
sm
okin
g u
se; n
o
chan
ge a
lcoh
ol u
se; m
argi
nal
chan
ge in
su
bst
ance
use
2
38S
torm
shak
, et
al
(201
1) 74
Van
Ryz
in, e
t al
(201
2) 75
N =
593
; 48.
6% F
emal
e;
Div
erse
pop
ula
tion
; 11.
88
(6th
gra
de)
3 se
ssio
ns
(you
th +
par
ent)
Sch
ool a
s u
sual
Sm
okin
g, a
lcoh
ol a
nd
sub
stan
ce u
se
24 m
o: r
edu
ced
sm
okin
g u
se,
red
uce
d a
lcoh
ol u
se, r
edu
ced
sub
stan
ce u
se; 3
6 m
o:
red
uce
d a
lcoh
ol u
se
4
39W
erch
, CE
et a
l
(199
8) 76
N =
211
; 49.
8% F
emal
e; 8
5%
Afri
can
Am
eric
an; 1
2.1
(6th
gra
de)
1 co
nsu
ltat
ion
(yo
uth
)+ 1
lett
er
+ 2
-9 w
orkb
ooks
(yo
uth
+
par
ent)
Boo
klet
on
alc
ohol
(you
th)
Alco
hol
use
init
iati
on
and
inte
nti
on
1 m
o: n
o ch
ange
alc
ohol
use
; 12
mo:
no
chan
ge a
lcoh
ol u
se
2
TABL
E 2
Con
tin
ued
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 138 , number 2 , August 2016
Studies varied in operationalization,
measurement of substance use
outcomes, which included tobacco,
alcohol, and illicit substance
intention to use, initiation, and
current use, as well as polysubstance
use. Twenty studies (48%) reported
3 substance use outcomes, 3 (7%)
reported 2 substance use outcomes,
15 (36%) reported 1 substance use
outcome, and 4 (9%) reported only
poly-substance use. Outcomes are
noted in Table 2 in the “Intervention
Description” column. Control
conditions were most often standard
care, leaflets, or no intervention. All
but 2 studies were conducted in the
United States. Eleven studies (29%)
included a majority of participants of
white/Caucasian/European origin,
11 studies (29%) focused on other
specific race/ethnic groups (5 on
African American, 1 on Asian, and 5
on Latino youth), 16 (38%) included
diverse youth populations, and 4 did
not report race/ethnicity.
Risk of Bias
Of the 42 included studies,
approximately half described how
the randomization sequences
were generated (n = 22, 52.4%),
approximately a third described
how these were concealed (n = 13,
31.0%), and few reported blinding
outcome evaluators (n = 9, 21.4%).
Many had high attrition rates and
were selective in the outcomes
that were reported in published
manuscripts (n = 16, 38.1% for both
domains). Summary counts of the
risk of bias assessment is presented
in Table 2 in the “Number of Low
Risk of Bias Criteria” column and
ranged from 0 (higher risk of bias,
1 study) to 4 (lower risk of bias, 7
studies) with an average number of
low risk of bias criteria of 2.3 ± 1.1
of a maximum score of 5. Because all
of the included studies had at least
1 feature that either was unclear or
posed high risk of bias to the study
findings (see Supplemental Table 3
for scoring on each criteria for each
11
Stu
dy
IDAu
thor
sYo
uth
Dem
ogra
ph
ics
Inte
rven
tion
Des
crip
tion
Con
trol
Des
crip
tion
Ou
tcom
es M
easu
red
Res
ult
sa (P
< .0
5)
Nu
mb
er L
ow R
isk
of B
ias
Cri
teri
ab
40W
erch
et
al
(200
3) 77
N =
650
; 46%
fem
ale;
Div
erse
pop
ula
tion
; 11.
4 (6
th
grad
e)
1 co
nsu
ltat
ion
+ 1
fol
low
-up
con
sult
atio
n (
you
th)
+ 1
0
pos
tcar
ds
+4
wor
kboo
ks
(you
th +
par
ent)
Boo
klet
on
alc
ohol
(you
th)
Alco
hol
use
init
iati
on
and
inte
nti
on
12 m
o: r
edu
ced
alc
ohol
inte
nti
on, n
o ch
ange
alc
ohol
use
or
init
iati
on
2
41W
est
et a
l (20
08) 78
N =
198
1; F
emal
e (N
A);
Cro
atia
n; 6
th–
8th
gra
de
Inte
rven
tion
en
cou
rage
s
par
ent-
child
com
mu
nic
atio
n
and
pee
r co
mm
un
icat
ion
(bas
ed o
n P
roje
ct
Nor
thla
nd
) (y
outh
+ p
aren
t)
Con
trol
sch
ools
(cu
rric
ulu
m is
stan
dar
d n
atio
nal
ly
in C
roat
ia)
Alco
hol
use
an
d
inte
nti
on
2 y:
red
uce
d a
lcoh
ol u
se; 3
y: n
o
chan
ge a
lcoh
ol u
se
1
42(a
)W
olch
ik e
t al
(200
2) 79
N =
157
; 49%
Fem
ale;
Pri
mar
ily C
auca
sian
; 10.
8
at b
asel
ine
Inte
rven
tion
1: 1
1 gr
oup
+ 2
ind
ivid
ual
ses
sion
s (p
aren
t)
Boo
ks o
n p
ostd
ivor
ce
adju
stm
ent
(par
ent)
Alco
hol
, su
bst
ance
and
pol
ysu
bst
ance
use
6 y:
no
chan
ge in
pol
ysu
bst
ance
use
3
42(b
)W
olch
ik e
t al
(200
2) 79
N =
159
; 51.
8% f
emal
e;
Pri
mar
ily C
auca
sian
; 10.
8
y at
bas
elin
e
Inte
rven
tion
2: 1
1 gr
oup
+ 2
ind
ivid
ual
ses
sion
s (p
aren
t)
+ 1
1 yo
uth
ses
sion
s
Boo
ks o
n p
ostd
ivor
ce
adju
stm
ent
(par
ent)
Alco
hol
, su
bst
ance
and
pol
ysu
bst
ance
use
6 y:
no
chan
ge in
pol
ysu
bst
ance
use
3
NA,
not
ava
ilab
le.
a R
edu
ctio
n, n
o d
iffe
ren
ce, o
r in
crea
se in
su
bst
ance
use
ou
tcom
e.b N
um
ber
of
Coc
hra
n C
rite
ria
ind
icat
ing
low
ris
k of
bia
s fr
om 0
to
5.
TABL
E 2
Con
tin
ued
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
ALLEN et al
study), the overall risk of bias of this
systematic review is high, suggesting
results must be interpreted with
caution. 11
Aim 1: Evidence for Intervention Effectiveness
Four studies reported only
polysubstance outcomes 4, 12, 34, 80 and
so are presented in Table 2 but not
in harvest plots. Of these, 3 were
effective at outcome end points
ranging from 12 to 30 months. 4, 12, 80
For smoking, 26 unique studies
assessed outcomes across the 4
time periods ( Fig 2, column 1).
The majority of studies reported
smoking as opposed to intent or
initiation; after 12 months, all but
1 study 81 reported smoking as the
outcome. The Xscores were significant
at all time points, indicating that
the proportion of studies showing
effective outcomes was greater than
what would be expected by chance.
However, the number of studies that
would need to be null to change this
conclusion was much lower at the
<12 months time point, suggesting a
trend toward increasing effectiveness
of interventions over time. The
fact that 2 of the effective studies
between 24.1 and 48 months 26, 28 and
1 of studies at >48 months27 reported
no significant intervention effect at
earlier time periods reinforces this
trend. There was variation in the
risk of bias in studies but no pattern
indicting that studies with greater
risk of bias were either more or less
effective than those with less risk of
bias.
Thirty-four studies reported alcohol
outcomes ( Fig 2, column 2), primarily
use as opposed to intent or initiation.
Effective studies at >24 months
either did not report early outcomes
or also indicated effectiveness at
earlier time periods. The Xscores were
significant at all time points. In this
case, the number of studies needed
to be null to change this conclusion
was highest at the early time points.
Variability in the studies’ risk of bias
was similarly distributed among
effective and ineffective studies.
Twenty-one studies examined
other illicit substance outcomes
( Fig 2, column 3), primarily use.
The Xscores were again significant at
all time points. Similar to alcohol,
the number of studies needed to be
null to change this conclusion was
highest at the early time points.
Again, there was variability in risk of
bias across effective and ineffective
interventions.
Across all 3 substances ( Fig 2, all
columns), few studies reported
efficacy across multiple substance
use outcomes. Three studies
indicated significant effects for
12
FIGURE 2Tobacco, alcohol, and illicit substance use, initiation, and intention outcomes according to length of participant follow-up. Black, substance use; gray, substance use initiation; white, substance use intention. Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore, number of studies needed to be null (NNN).
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 138 , number 2 , August 2016
preventing or reducing use of 2
substances at <12 months, 10, 21, 27 2
at 12 to 24 months, 14, 20 4 at 24 to
48 months, 15, 25, 26, 28 and 2 at >48
months. 7, 18 In terms of preventing all
3 substances, 1 study showed efficacy
at <12 months, 18 2 at 12 to 24
months, 18, 25 1 at 24 to 48 months, 18
and none at >48 months.
Aim 2: Characteristics of Effective Interventions
For this aim, we assessed the
participants, dosage, settings,
and delivery methods of effective
interventions. In terms of targeted
participants, interventions largely
included parents and youth; Xscores
for each outcome were as follows:
tobacco, 18.83, P < .001; alcohol,
20.97, P < .001; illicit drug use, 19.94,
P < .001; and polydrug use, 17.94, P <
.001. Seven interventions, 1, 6, 9(a),
14(a), 16(a), 18, and 42(a), focused
exclusively on parents (see Table 2).
Only 1 of these reported significant
results. 82
For the 26 studies reporting
smoking outcomes, 69% reported
information that allowed calculating
the intervention dosage, 81%
reported delivery setting, and 96%
reported delivery method ( Fig 3).
In terms of dosage, ( Fig 3, column
1), the majority of effective studies
reported <12 hours of training,
although Xscores were significant at all
dosages. Most of the interventions
reported delivery setting as schools
or a combination of settings ( Fig 3,
column 2). Xscores were significant
for all settings. Results regarding
delivery method suggest that most
of the effective interventions used
sessions with a professional ( Fig 3,
column 3), as indicated by the high
number of studies needed to be null
to disprove this conclusion. The few
studies using either printed material
or computer-based approaches
reported inconsistent findings.
For the 34 studies reporting
alcohol outcomes, 65% reported
the intervention dosage, 85%
reported delivery setting, and 94%
reported delivery method ( Fig 4).
In terms of dosage ( Fig 4, column
1), the majority of effective studies
reported <12 hours of training. Most
were delivered at home, school, or
in a combination of settings; those
delivered at home had the highest
Xscores ( Fig 4, column 2). Most studies
reporting alcohol outcomes used
sessions; however, all that used a
computer-based approach were
effective ( Fig 4, column 3).
For the 21 studies reporting illicit
substance use outcomes, 86%
reported the intervention dosage,
81% reported delivery setting, and
95% reported delivery method ( Fig
5). In terms of dosage ( Fig 5, column
1), most effective interventions
13
FIGURE 3Tobacco use at the longest follow-up time according to dose of intervention, setting, primary delivery method, and program duration. White columns, ≤12 months of follow-up; dotted columns, 12.1–24 months of follow-up; horizontal stripe columns, 24.1–48 months of follow-up; black, >48 months of follow-up. Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore, number of studies needed to be null (NNN).
by guest on January 2, 2020www.aappublications.org/newsDownloaded from
ALLEN et al
included ≤24 hours of training,
although Xscores were significant
for all dosages. There was a variety
of effective delivery settings for
illicit substances ( Fig 5, column 2);
most occurred in schools or in a
combination of settings. The majority
of these studies used sessions with
a professional as their delivery
method ( Fig 5, column 3). Xscores were
significant for all delivery methods
except for computer based.
DISCUSSION
Results of this systematic review
indicate that parenting interventions
could be effective at preventing
and decreasing adolescent tobacco,
alcohol, and illicit substance use
but that the substance of focus
and delivery characteristics are
important. The finding that Xscores
were highly significant for all
outcomes at all time periods supports
the conclusion that parent-focused
interventions may generate a
reduction on youth substance use
over the short and long term.
Despite the existence of multiple
effective programs, prevention
researchers have noted that uptake
of evidence-based programming has
been limited. 81 Common challenges
for translation of evidence-based
interventions to nonresearch settings
include intervention intensity, a
discrepancy between skills needed
to implement the interventions
and those available with current
staff, and intervention relevance (to
population or setting). 2 Maximal
reach of interventions in this review
would be achieved if evidence existed
for a broad menu of minimally
burdensome delivery modalities that
could be easily accessed by families
across a variety of settings and
impact multiple outcomes, yet our
results suggest a relatively limited set
of options.
On the encouraging side, our
findings indicate that relatively
low-intensity interventions with
a dosage of a manageable ≥12
parent contact hours achieve
outcomes. Although the dosage is
manageable, the delivery modality
may be problematic. The finding
that group sessions were the most
common means for delivering
these interventions to parents
and youth may pose barriers for
some community settings. When
implemented well, in-person group
sessions may be powerful because
of social support and shared
learning among the participants;
however, high-quality sessions
require dedicated staff with content
expertise, strong facilitation skills,
and high-intensity training on
intervention implementation. The
costs and staff requirements may
be beyond the means of community
organizations, particularly those
in resource-limited settings where
14
FIGURE 4Alcohol use at the longest follow-up time according to dose of intervention, setting, primary delivery method, and program duration. White columns, ≤12 months of follow-up; dotted columns, 12.1–24 months of follow-up; horizontal stripe columns, 24.1–48 months of follow-up; black columns, >48 months of follow-up. Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore, number of studies needed to be null (NNN).
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PEDIATRICS Volume 138 , number 2 , August 2016
highest at-risk youth are often served
and reside. In this review, alcohol use
was unique among the substances
in that multiple effective studies
used computer-based delivery
modalities. The success of these
interventions suggests that this may
be an effective and presumably less
costly approach to reaching a larger
group of parents of youth. An added
benefit of computer-based delivery
is that content may be tailored to a
particular family’s needs or cultural
preferences, increasing the likelihood
of relevance and effectiveness. 83
In sum, although group sessions
represent the most common and
evidence-based delivery modality
for tobacco and illicit substance use
prevention in particular, there is
need for additional studies using
alternative approaches, including
social/online media, to develop a
broader set of options for translation
of effective programs.
Overall, many studies were delivered
in a combination of settings, largely
schools and home. Few studies
occurred in nonschool community
agencies, such as health clinics.
There is evidence that parenting
interventions can be successfully
implemented in health care
settings, yet few studies have
made use of clinics as locations for
implementation of family-based
substance use prevention. 84, 85 As
schools become overburdened with
initiatives focusing on academic
achievement, it is important to
consider clinics and community
agencies as alternative settings to
promote, sustain, and fund parent
training programming. This is
particularly true with the increased
focus on “moving prevention to
the mainstream of health, ” clinical-
community and public health
partnerships promoted through
the Affordable Care Act, 82 and
integrated care within family- and
patient-centered health care homes. 8
This approach has shown positive
results with newborns86; more
research is needed to understand
which delivery modalities are
most appropriate for the clinic
environment and how policies and
clinical procedures can best sustain
these effective programs with
adolescents.
Finally, given limited resources
available for prevention
programming and competing
demands within delivery agencies,
parent-focused interventions would
ideally effectively target multiple
substance use outcomes; however,
few studies were effective at reducing
adolescent use of multiple substances
over the long term. Future research
should investigate common core
principles, content, and delivery
modalities that contribute to study
outcomes for a given substance use
to enhance programming in a manner
that will increase the likelihood of
15
FIGURE 5Illicit substance use at the longest follow-up time according to dose of intervention, setting, primary delivery method, and program duration. White columns, ≤12 months of follow-up; dotted columns, 12.1–24 months of follow-up; horizontal stripes, 24.1–48 months of follow-up; black columns, >48 months of follow-up. Taller columns represent studies with lower risk of bias. Numbers indicate study ID. Xscore, number of studies needed to be null (NNN).
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ALLEN et al
interventions being efficacious across
substances.
This study has notable strengths,
including use of broad inclusion
criteria to identify all relevant
intervention studies, but given
that the majority of studies had
risk of bias based on available
data, the overall conclusions must
be interpreted with caution. 11
Conclusions were limited by the
degree to which authors adhered
to the CONSORT (Consolidated
Standards of Reporting Trials)
guidelines for behavioral
interventions when reporting study
design and findings, particularly
in the areas of randomization
sequence generation and blinding of
data collection processes. 87 Better
reporting of risk of bias outcomes
within articles would potentially
have increased the strength of our
recommendations but not the results
of our review. In addition, because
of the heterogeneity of intervention
components, contexts, samples,
methods, outcomes, and measures,
we did not perform a meta-analysis
and instead used harvest plots to
summarize the study findings and
explore the effects of intervention
delivery methods on tobacco,
alcohol, and substance use outcomes.
Although this approach does not
provide effect estimate summaries as
in meta-analyses, it is an alternative
that visually represents different
aspects of intervention complexity. 80
In addition, using the binomial test
of proportions to complement the
harvest plots allowed us to estimate
probabilities of observing the
presented patterns of results, which
produced quantitative evidence
supporting the qualitative summary.
The high number of studies needed to
be null to change study conclusions
support the findings of our review.
With the increased move to
translate effective interventions
into broad use and the call for
collaboration between clinic
and public health initiatives to
promote disease-preventing
programming, there is need to
identify effective interventions that
prevent adolescent substance use
across multiple delivery modalities
and settings, including clinics.
Parent training interventions are
an effective means to promote
public health goals for adolescents,
and an opportunity remains to
extrapolate what works to varied
community settings in a manner that
prevents adolescent use of multiple
substances.
ACKNOWLEDGMENTS
The authors acknowledge the
substantial contribution of Nicole
Hassig in formatting the harvest
plots.
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Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.
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DOI: 10.1542/peds.2015-4425 originally published online July 21, 2016; 2016;138;Pediatrics
Patel, Jonathan Miller and Iris BorowskyMichele L. Allen, Diego Garcia-Huidobro, Carolyn Porta, Dorothy Curran, Roma
ReviewEffective Parenting Interventions to Reduce Youth Substance Use: A Systematic
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DOI: 10.1542/peds.2015-4425 originally published online July 21, 2016; 2016;138;Pediatrics
Patel, Jonathan Miller and Iris BorowskyMichele L. Allen, Diego Garcia-Huidobro, Carolyn Porta, Dorothy Curran, Roma
ReviewEffective Parenting Interventions to Reduce Youth Substance Use: A Systematic
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